Healthcare Provider Details

I. General information

NPI: 1225028327
Provider Name (Legal Business Name): COMMUNITY CONVALESCENT HOSPITAL OF LA MESA LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8665 LA MESA BLVD
LA MESA CA
91941
US

IV. Provider business mailing address

8665 LA MESA BLVD
LA MESA CA
91941-3903
US

V. Phone/Fax

Practice location:
  • Phone: 619-465-0702
  • Fax: 619-828-1782
Mailing address:
  • Phone: 619-465-0702
  • Fax: 619-828-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number090000033
License Number StateCA

VIII. Authorized Official

Name: MR. JACOB GRAFF
Title or Position: PRESIDENT
Credential:
Phone: 323-556-0040